Section_16_Authorizations_Legacy_version_20140106.doc

Requirements Specification Document (LEGACY DRAFT)

Authorizations (Section16)

Central Bill Process

Authorizations (PWS Section 16) Requirements Specifications Document

(LEGACY DRAFT)

Prepared for:

U.S. Department of Labor Office of Worker’s Compensation Programs

Revision History:

SPECIAL NOTICE: This document is a legacy draft requirements specification document developed between 2011 and 2012. As outlined in the Performance Work Statement, the Contractor will be required to review this RSD and make appropriate updates wherever necessary. (Please refer to PWS R0052 for more details.)

Table of Contents Authorizations - DFEC

61.1 Authorizations Overview – DFEC

61.2 Authorizations Business Process Description – DFEC

91.3 Authorizations Business Process Flow – DFEC

91.3.1 Authorizations Overview

101.3.2 Mail Authorization Submission

111.3.3 Fax Authorization Submission

121.3.4 Web Authorization Submission

131.3.5 Level 2 Authorization Process

141.3.6 Level 3 Authorization Process at CE Level

151.3.7 Emergency/Urgent Authorization Process

161.3.8 Travel/Transportation Authorization Process

171.3.9 Exact Duplicate Authorization Validation

181.3.10 Claims Processing Authorization Process

Authorizations – DEEOIC

192.1 Overview – DEEOIC

192.2 Authorizations Business Process Description – DEEOIC

232.3 Authorizations Business Process Flow – DEEOIC

232.3.1

242.3.2 Mail Authorization Submission

252.3.3 Fax Authorization Submission

262.3.4 Web Authorization Submission

282.3.5 Level 2 Authorization Process

292.3.6 Level 3 Authorization Process at CE Level

302.3.7 Emergency/Urgent Authorization Process

312.3.8 Travel/Transportation Authorization Process

322.3.9 Exact Duplicate Authorization Validation

332.3.10

Authorizations – DCMWC

343.1 Overview – DCMWC

343.2 Authorizations Business Process Description – DCMWC

363.3 Authorizations Business Process Flow – DCMWC

363.3.1

373.3.2

Authorizations Requirements

384.1 Functional Requirements

424.2 Business Rules

Authorizations Supporting Functional Components

635.1 Initial Data Migration

635.2 Interfaces

645.3 Reports

675.4 Letters

Constraints

696.1 Assumptions

696.2 Dependencies

696.3 Issues/Open Items

Appendices

707.1 Terms & Definitions

757.2 DFEC Authorization Form RTP Criteria

787.3 DEEOIC Authorization Form RTP Criteria

1 Authorizations - DFEC

1.1 Authorizations Overview – DFEC

1.2 Authorizations Business Process Description – DFEC

The prompt and accurate review and processing of all authorization requests is essential for DOL to ensure that all beneficiaries receive the correct level of medical care as defined through the Treatment Suites relationship between accepted conditions that lead to approved treatments. The proper vetting of authorizations reduces backlogs of medical bills, speeds payments to providers for approved services, and reduces the potential for fraud and abuse. The Contractor’s experienced medical staff, supported by electronic work flows and centralized image files, will perform efficient, consistent, and objective authorization decisions based on the Government’s authorization rules for Level 1 or Level 2 authorizations. For Level 3 authorizations, the DOL program responsible will have access to automated work queues to review and take action on authorization requests.

The CBP solution will store authorization requests and their associated attachments in the image repository. Automated workflows will queue these requests for processing in the order in which they are received — received either from the Contractor CBP Call Center, from mail requests through the mailroom, via facsimiles, or electronically from the Contractor CBP Web Portal. Authorization decisions forwarded to the DOL claims examiners will contain a link to the authorization images including the authorization request and any supporting documentation and attachments. Level 1 requests for treatments authorized through the Treatment Suites functionality will be automatically processed by the CBP. All Level 2 and Level 3 authorizations will be tracked through the automated workflows to completion.

The CBP will not permit un-enrolled, excluded, or deactivated providers to submit authorization requests. If an authorization request is received from a non-active provider, the provider will receive an RTP, and the authorization request will not be processed. Authorization requests requiring CE intervention (level 2 or 3 that the Contractor cannot authorize) are forwarded through the automated work queue. If the authorization is going to deny (for example because of a treatment suite edit), the CE has the ability to override the denial via the DD Exception process. It is the CE’s responsibility to determine if the request is approved or denied. The CE will communicate denials to the provider. As a request progresses to a final decision, the information available through IVR, the Contractor CBP Web Portal, and through the Contractor CBP Call Center is updated.

The Contractor will make dispositions on all authorization requests within 2 business days of receipt based on the date and time stamp and for Level 3 authorizations, establish a procedure through its automated workflows and queues to track the Government’s response. This process will provide traceability of the dates that the requests were submitted and the dates that the Government responds. The Contractor will make available to authorized Contractor and DOL staff all images of authorization requests (including faxed and paper submitted) and their associated attachments within a monthly average of 1 business day via the CBP image repository and CBP Web Portal. Outgoing authorizations will be imaged and immediately made available to authorized CBP users. Electronic DFEC authorizations will be transmitted to DOL via the DFEC imaging process.

The Contractor will provide the following capabilities for authorization requests, depending on the authorization level returned from Treatment Suites:

For Level 1 requests, the provider will be informed that an authorization is not required.

Level 2 requests will be forwarded to the Contractor authorization unit to research the request according to DOL reviewed and approved guidelines based on the appropriate rule that applies to the request. For Level 2 requests that the Contractor is able to resolve and approve, the request status is updated to approved, which automatically triggers a letter to be generated to the provider. The Contractor will disposition Level 2 medical requests within 2 business days.

For Level 2 requests where the the Contractor Authorization unit is unable to make a determination and approve the request, the authorization status will be updated to “pending,” and the authorization request will be changed to Level 3. The request and all supporting documentation will be electronically forwarded to the appropriate DOL DO for automated work queue review and approval. Once DOL approves the Level 3 request, the Contractor will be notified through the automated workflows and queues. The Contractor will update the authorization status from pending to approved, which will automatically trigger a letter to be generated to the provider. The Contractor will ensure that this process for Level 3 requests is completed within 1 business day of DOL notification. For Level 3 requests where DOL determines that further development is required, the Contractor will be notified through the automated workflows and queues. The Contractor will update the authorization status from pending to under development, which will automatically trigger a letter to be generated to the provider stating the request is under review by the Government.

The Contractor authorization unit will receive phone calls requesting authorizations through the Call Center. Emergency and urgent requests will be transferred to the triage nurses from the Contractor CBP Call Center. Upon review, the triage nurses will communicate via telephone these emergency and urgent requests to the respective District Office and requesting provider immediately after receiving the request, and an electronic record of the authorization will be entered within 1 business day of receipt of the authorization request.

The CBP will provide the ability to authorize services based on units of service, dollar amounts, diagnosis codes, procedure codes and ranges, maximum amounts as defined by DOL, date ranges or specific dates, length (e.g., number of days), NDC/GCN, TC, and provider number. All authorization requests will be verified to contain valid information (e.g., claimant name, case number, procedure code, provider id), and any requests that have been faxed with incomplete information will be returned via fax to the requesting provider.

All authorizations will be assigned unique numbers to identify them and will be associated with the specific program to which the claimant is a member. Authorizations will be stored in the CBP database and be immediately accessible to facilitate real-time responses on status (approved, denied, pending) to authorized DOL and Contractor staff, as well as providers.

The CBP will be configured to prevent duplicate authorizations from being entered. Data integrity is very critical to bill processing, and the Contractor will ensure that requests for the same provider number, procedure, claimant, and same or overlapping dates of service are treated as duplicates and will not be entered into the system.

The authorization file will be accessed by bill processing so that any bills that are submitted that have been approved for special or extra care services will be processed automatically, and if there is a matching authorization on file, the services, quantities, and/or dates will be updated automatically. If the dates don’t match, the quantities have been exceeded, or there are other problems, the bill line(s) will post the appropriate edits. As the medical bills are processed against the matching authorization record, the quantities, units, dollar amounts, dates, and other authorized units of measure that were approved on the authorization will be decremented, and the approved amounts and the used amounts will be readily identifiable from the authorization records on file. For adjustments and voids of bills that contain bill lines for authorized services, the adjustment will credit the original amount (e.g., units, dollars, length) deducted from the authorization record and debit the corrected or the appropriate amount from the authorization record. For voids, the quantities will be credited back to the authorization record, effectively removing the original amount that was debited.

CBP will be configured to allow diagnostic services to be authorized only in unaccepted cases when approved by DOL. Treatment Suites will be used for all authorization requests to determine if the requested procedure requires an authorization based on the accepted condition of the claimant. The Contractor will implement a real-time solution to provide this information via the CBP Portal and IVR. This will allow providers, as well as the Contractor and DOL staff, to determine if authorizations are required for particular services.

The Contractor will support receiving authorization requests in several types of media, including fax, paper, voice, electronic (CBP Web Portal and IVR). Faxed requests on incorrect forms will automatically, if the incoming fax number can be identified, result in a fax back notification that an incorrect form was used, along with a full set of the correct blank authorization forms. The Contractor will also implement automated checks for required and valid data on all incoming authorization requests. The Contractor will notify providers either through a real-time response via the CBP Web Portal or IVR, fax back notification, or letter, that the request contained missing or invalid data, or was not in compliance with all Government policies.

For the majority of services submitted for authorization, the Contractor will implement automated processes to first determine the authorization level of the service requested by calling Treatment Suites. If the authorization level returned from Treatment Suites is Level 2 or 3, the Contractor will implement automated processes to capture the data from these forms and create an authorization record in the CBP. If the authorization level returned is Level 1, no action other than generating an automated notification to the Provider will be taken.

The Contractor Call Center will support the authorization process as well, by handling calls for prior authorizations and triage processing. All Call Center staff will utilize Treatment Suites to determine authorization requirements. For Level 1 authorizations, Call Center staff can notify providers immediately that the service is covered, and an authorization request does not need to be submitted. For Level 2 and 3 requests, Call Center staff will route the authorization requests to the the Contractor authorization unit, specifically the triage nurses for further processing.

The Contractor will implement automated workflows and queues to assign and route certain Level 2 and all Level 3 authorization requests to the appropriate District Office/CE for further disposition. The automated workflows will track all requests that have been routed, ensuring all requests are being processed within the required timeframes, and generating alerts when timeframes are in jeopardy of being exceeded. Upon receiving determination from CEs on Level 2 and 3 authorization requests, the Contractor will update the authorization status accordingly, and communicate both approval and pending status authorizations to providers. The Contractor understands that only DOL will communicate authorization denials. All requests, whether worked by the Contractor or DOL, are tracked throughout the entire authorization process (from request assignment to final determination) and response time statistics are generated to ensure all authorization requests are processed timely.

Authorization status is made available to requesting providers and claimants, through self-service functions via the CBP Web Portal and IVR, as well as by calling the Call Center. The Contractor will also generate and distribute authorization letters, to providers communicating approval, pending, or further development status.

1.3 Authorizations Business Process Flow – DFEC

The following diagrams capture the various DFEC Authorizations Business Process flows.

1.3.1 Authorizations Overview

1.3.2 Mail Authorization Submission

1.3.3 Fax Authorization Submission

1.3.4 Web Authorization Submission

1.3.5 Level 2 Authorization Process

1.3.6 Level 3 Authorization Process at CE Level

1.3.7 Emergency/Urgent Authorization Process

1.3.8 Travel/Transportation Authorization Process

1.3.9 Exact Duplicate Authorization Validation

1.3.10 Claims Processing Authorization Process

2 Authorizations – DEEOIC

2.1 Overview – DEEOIC

The authorization process is a critical function of the CBP. Requests for medical services ordered by a physician are reviewed by medically trained personnel to ensure that the requests meet the guidelines for medical necessity set forth by DOL for the accepted condition and approved treatment modalities. The CBP solution will be fully integrated with mailroom, imaging, and bill processing workflows to enable our experienced medical staff to review and approve Level 2 authorizations regardless of whether these requests are received by telephone, fax, electronically, or by mail. Status of these requests will be available and tracked within the Contractor CBP Solution through automated workflow and assigned work queues. Secure access to approval data through the Contractor CBP Web Portal facilitates Government review and approval of Level 3 authorizations and certain Level 2 authorizations. Telephone, interactive voice response (IVR), and the Contractor CBP Web Portal will provide a rapid method for providers to get a status of their authorization request.

The authorization process is the gateway to ensuring that trained medical professionals, escalation processes, secure data handling and other business processes are used to ensure the accuracy of allowed expenses.

2.2 Authorizations Business Process Description – DEEOIC

The prompt and accurate review and processing of all authorization requests is essential for DOL to ensure that all beneficiaries receive the correct level of medical care as defined through the Treatment Suites relationship between accepted conditions that lead to approved treatments. The proper vetting of authorizations reduces backlogs of medical bills, speeds payments to providers for approved services, and reduces the potential for fraud and abuse. The Contractor’s experienced medical staff, supported by electronic work flows and centralized image files, will perform efficient, consistent, and objective authorization decisions based on the Government’s authorization rules for Level 1 or Level 2 authorizations. For Level 3 authorizations, the DOL program responsible will have access to automated work queues to review and take action on authorization requests.

The CBP solution will store authorization requests and their associated attachments in the image repository. Automated workflows will queue these requests for processing in the order in which they are received — received either from the Contractor‘sCBP Call Center, from mail requests through the mailroom, via facsimiles, or electronically from the Contractor’s CBP Web Portal. Authorization decisions forwarded to the DOL claims examiners will contain a link to the authorization images including the authorization request and any supporting documentation and attachments. Level 1 requests for treatments authorized through the Treatment Suites functionality will be automatically processed by the CBP. All Level 2 and Level 3 authorizations will be tracked through the automated workflows to completion.

The CBP will not permit un-enrolled, excluded, or deactivated providers to submit authorization requests. If an authorization request is received from a non-active provider, the provider will receive an RTP, and the authorization request will not be processed. Authorization requests requiring CE intervention (level 2 or 3 that the Contractor cannot authorize) are forwarded through an automated work queue. If the authorization is going to deny (for example because of a treatment suite edit) the request should be forwarded to the appropriate District Office noting that the service is not covered in the treatment suite. The DO will determine if the request is approved or denied. The DO will communicate denials to the provider. As a request progresses to a final decision, the information available through IVR, the the Contractor CBP Web Portal, and through the Contractor CBP Call Center will be updated.

The Contractor will make dispositions on all authorization requests within 2 business days of receipt based on the date and time stamp and for Level 3 authorizations, establish a procedure through its automated workflows and queues to track the Government’s response. This process will provide traceability of the dates that the requests were submitted and the dates that the Government responds. The Contractor will make available to authorized Contractor and DOL staff all images of authorization requests (including faxed and paper submitted) and their associated attachments within a monthly average of 1 business day via the CBP image repository and CBP Web Portal. Outgoing authorizations will be imaged and immediately made available to authorized CBP users.

The Contractor will provide the following capabilities for authorization requests, depending on the authorization level returned from Treatment Suites:

For Level 1 requests, the provider will be informed that an authorization is not required.

Level 2 requests will be forwarded to the Contractor authorization unit to research the request according to DOL reviewed and approved guidelines based on the appropriate rule that applies to the request. For Level 2 requests that the Contractor is able to resolve and approve, the request status is updated to approved, which automatically triggers a letter to be generated to the provider. The Contractor will disposition Level 2 medical requests within 2 business days.

For Level 2 requests where the Contractor Authorization unit is unable to make a determination and approve the request, the authorization status will be updated to “pending,” and the authorization request will be changed to Level 3. The request and all supporting documentation will be electronically forwarded to the appropriate DOL DO for automated work queue review and approval. Once DOL approves the Level 3 request, the Contractor will be notified through the automated workflows and queues. The Contractor will update the authorization status from pending to approved, which will automatically trigger a letter to be generated to the provider. The Contractor will ensure that this process for Level 3 requests is completed within 1 business day of DOL notification. For Level 3 requests where DOL determines that further development is required, the Contractor will be notified through the automated workflows and queues. the Contractor will update the authorization status from pending to under development.

The Contractor authorization unit will receive phone calls requesting authorizations through the Call Center. Emergency and urgent requests will be transferred to the triage nurses from the Contractor CBP Call Center. Upon review, the triage nurses will communicate via telephone these emergency and urgent requests to the respective District Office and requesting provider immediately after receiving the request, and an electronic record of the authorization will be entered within 1 business day of receipt of the authorization request.

The Contractor will provide the ability to authorize services based on units of service, dollar amounts, diagnosis codes, procedure codes and ranges, maximum amounts as defined by DOL, date ranges or specific dates, length (e.g., number of days), NDC/GCN, TC, and provider number. All authorization requests will be verified to contain valid information (e.g., claimant name, case number, procedure code, provider id), and any requests that have been faxed with incomplete information will be returned via fax to the requesting provider.

All authorizations will be assigned unique numbers to identify them and will be associated with the specific program to which the claimant is a member. Authorizations will be stored in the CBP database and be immediately accessible to facilitate real-time responses on status (approved, denied, pending) to authorized DOL and Contractor staff, as well as providers.

The CBP will be configured to prevent duplicate authorizations from being entered. Data integrity is very critical to bill processing, and the Contractor will ensure that requests for the same provider number, procedure, claimant, and same or overlapping dates of service are treated as duplicates and will not be entered into the system.

The authorization file will be accessed by bill processing so that any bills that are submitted that have been approved for special or extra care services will be processed automatically, and if there is a matching authorization on file, the services, quantities, and/or dates will be updated automatically. If the dates don’t match, the quantities have been exceeded, or there are other problems, the bill line(s) will post the appropriate edits. As the medical bills are processed against the matching authorization record, the quantities, units, dollar amounts, dates, and other authorized units of measure that were approved on the authorization will be decremented, and the approved amounts and the used amounts will be readily identifiable from the authorization records on file. For adjustments and voids of bills that contain bill lines for authorized services, the adjustment will credit the original amount (e.g., units, dollars, length) deducted from the authorization record and debit the corrected or the appropriate amount from the authorization record. For voids, the quantities will be credited back to the authorization record, effectively removing the original amount that was debited.

Treatment Suites will be used for all authorization requests to determine if the requested procedure requires an authorization based on the accepted condition of the claimant. The Contractor will implement a real-time solution to provide this information via the CBP Portal and IVR. This will allow providers, as well as Contractor and DOL staff, to determine if authorizations are required for particular services.

The Contractor will support receiving authorization requests in several types of media, including fax, paper, voice, electronic (CBP Web Portal and IVR). Faxed requests on incorrect forms will, if the incoming fax number can be identified, automatically result in a fax back notification that an incorrect form was used, along with a full set of the correct blank authorization forms. The Contractor will also implement automated checks for required and valid data on all incoming authorization requests. The Contractor will notify providers either through a real-time response via the CBP Web Portal or IVR, fax back notification, or letter, that the request contained missing or invalid data, or was not in compliance with all Government policies.

For the majority of services submitted for authorization, the Contractor will implement automated processes to first determine the authorization level of the service requested by calling Treatment Suites. If the authorization level returned from Treatment Suites is Level 2 or 3, the Contractor will implement automated processes to capture the data from these forms and create an authorization record in the CBP. If the authorization level returned is Level 1, no action other than generating an automated notification to the Provider will be taken.

The Contractor’s Call Center will support the authorization process as well, by handling calls for prior authorizations and triage processing. All Call Center staff will utilize Treatment Suites to determine authorization requirements. For Level 1 authorizations, Call Center staff will notify providers immediately that the service is covered, and an authorization request does not need to be submitted. For Level 2 and 3 requests, Call Center staff will route the authorization requests to the Contractor authorization unit, specifically the triage nurses for further processing.

The Contractor will implement automated workflows and queues to assign and route certain Level 2 and all Level 3 authorization requests to the appropriate District Office/CE for further disposition. The automated workflows will track all requests that have been routed, ensuring all requests are being processed within the required timeframes, and generating alerts when timeframes are in jeopardy of being exceeded. Upon receiving determination from CEs on Level 2 and 3 authorization requests, the Contractor will update the authorization status accordingly, and communicate approved status authorizations to providers. The Contractor should understand that only DOL will communicate authorization denials. All requests, whether worked by the Contractor or DOL, are tracked throughout the entire authorization process (from request assignment to final determination) and response time statistics are generated to ensure all authorization requests are processed timely.

Authorization status is made available to requesting providers and claimants, through self-service functions via the CBP Web Portal and IVR, as well as by calling the Call Center. The Contractor will also generate and distribute authorization letters to providers communicating approved status.

2.3 Authorizations Business Process Flow – DEEOIC

The following diagrams capture the various DEEOIC Authorizations Business Process flows.

2.3.1 Authorizations Overview

2.3.2 Mail Authorization Submission

2.3.3 Fax Authorization Submission

2.3.4 Web Authorization Submission

2.3.5 Level 2 Authorization Process

In the current state, this Level 2 Authorization Process does not apply to DEEOIC, but will likely be a part of their future state process.

2.3.6 Level 3 Authorization Process at CE Level

2.3.7 Emergency/Urgent Authorization Process

2.3.8 Travel/Transportation Authorization Process

2.3.9 Exact Duplicate Authorization Validation

2.3.10 Claims Processing Authorization Process

3 Authorizations – DCMWC

3.1 Overview – DCMWC

The authorization process is a critical function of the CBP. Authorizations for DCMWC claimants are received from DOL through a daily authorization interface file. Authorizations come in the form of a Diary Action Code (DAC) or Certificate of Medical Necessity (CMN). Diary Action Codes are used to authorize determination testing services. Certificates of Medical Necessity are used to authorize treatment services.

The authorization process is the gateway to ensuring that trained medical professionals, escalation processes, secure data handling and other business processes are used to ensure the accuracy of allowed expenses.

3.2 Authorizations Business Process Description – DCMWC

The prompt and accurate review and processing of all authorization requests is essential for DOL to ensure that all beneficiaries receive the correct level of medical care as defined through the Treatment Suites relationship between billed diagnoses that lead to approved treatments. The proper vetting of authorizations reduces backlogs of medical bills, speeds payments to providers for approved services, and reduces the potential for fraud and abuse.

The Contractor will accept authorizations from DCMWC for PPA bills (diary action codes) and certain DME/Pulmonary Rehab/Nursing Home bills (CMN codes) and ‘Pend’ drug bills for services that require prior approval, to be used in bill processing. There will not be a Certificate of Medical Necessity (CMN) for PPA bills

The diary action code authorization interface contains authorization records for those claimants undergoing determination testing. Diary action codes (DACs) map to specific procedures as well as a maximum number of units. A Diary record can be uniquely identified by the combination of miner_ssn, claim_type, claim_record_no, diary_line_no, diary_action_code and diary_start_date. CBP must process multiple DAC files in the proper sequence.

Authorizations for claimants undergoing treatment services are received on the Certificate of Medical Necessity (CMN) interface file. DCMWC requires the use of form CM-893 for pre-approval and requires medical justification for the prescribed equipment. Upon approval of the CMN, DO staff notifies the doctor, the supplier, and the patient and enters an authorization for the CMN.

Upon entry, the authorization is forwarded to the medical bill processing system. The same pre-approval process is used for home nursing services and pulmonary rehabilitation. These services are not approved by the contractor. If authorization is not approved by the District Office the bills are denied.

Certain DME, pulmonary rehab, and home nursing codes will require the default diagnosis of 496. These procedure codes require a Certificate of Medical Necessity (CMN) to be submitted by the prescribing physician to the District Office for review and approval.

A CMN record can be uniquely identified by the combination of cmn_miner_ssn, service_type, cmn_procedure_cd and cmn_rec_seq_no. CMN interface records must be processed in the correct sequence.

Error files are also generated as part of the authorization process for both DAC and CMN. In order to ensure that files do not process out of sequence, if an entire file is rejected, then no DAC/CMN interface files can be processed until the rejected file is re-submitted.

All authorizations will be assigned unique numbers to identify them and will be associated with the specific program to which the claimant is a member. Authorizations will be stored in the CBP database and be immediately accessible to facilitate real-time responses on status (approved or denied) to authorized DOL and the Contractor staff, as well as providers.

The authorization file will be accessed by bill processing so that any bills submitted for services that require an authorization are not paid if services have not been authorized. The system will attempt to match to an authorization based on claimant, provider, procedure/s and dates of service. If an exact match is not found, the appropriate edits will apply. If an exact match is found, the authorization will be applied to the bill, and decrement the units or dollars (if applicable) that were paid. Bills that are adjusted in any manner will credit or debit back any amounts that were previously applied to the authorization.

Treatment Suites will be used to determine if the requested procedure requires an authorization. DME/Pulmonary Rehab/Skilled Nursing (diagnosis 500), and PPA bills (diagnosis V81.30) are the only bills that require authorizations. The Contractor will implement a real-time solution to provide this information via the CBP Portal and IVR. This will allow providers, as well as Contractor and DOL staff, to determine if authorizations are required for particular services.

Authorization status is made available to requesting providers and claimants, through self-service functions via the CBP Web Portal and IVR, as well as by calling the Call Center.

3.3 Authorizations Business Process Flow – DCMWC

The following diagrams capture the various DCMWC Authorizations Business Process flows.

3.3.1 Authorizations Overview

3.3.2 Claims Processing Authorization Process

NOTE: Treatment Suites is not used for Inpatient bill processing for DCMWC.

4 Authorizations Requirements The following section documents the functional requirements and business rules needed to implement the requirements outlined in Section 16 – Authorizations of the PWS. For requirements traceability purposes, IDs have been assigned to each functional requirement and business rule. The first two characters of each ID represent the related Program number, (B1 (Core/DFEC), B2 (DEEOIC), B3 (DCMWC), followed by PWS Section, followed by a 3 digit sequentially assigned number within each Build/PWS Section. The Program column indicates whether the requirement/rule is Core (i.e., applies to all programs) or if it is DFEC, DEEOIC, and/or DCMWC specific.

4.1 Functional Requirements

PWS

Req # Functional

Req ID

B1-16-BR001

B2-16-BR001

Core

N/A

DCMWC

R0602

R0640

B2-16-BR001

Core

R0602

R0640

N/A

DCMWC

R0602

R0640 R0015

B2-16-BR002

Core

R0602

R0640

N/A

DCMWC

R0604

R0605

R0611

R0628

B2-16-BR016

Core

R0604

R0605

R0611

R0628

N/A

DCMWC

R0602

R0605

R0609

R0635

R0636

R0639

B1-16-FR005

B2-16-BR001 B1-16-BR002

B2-16-BR002 B1-16-BR003

B1-16-BR004

B1-16-BR005

B1-16-BR015

B1-16-BR029

Core

R0602

R0605

R0609

R0635

R0636

B3-16-FR005

B1-16-FR005 does not apply to DCMWC.

B3-16-BR003

B3-16-BR004

B3-16-BR005

B3-16-BR029

DCMWC

R0605

R0623

R0629

R0630

R0631

R0632

R0633

B1-16-FR006

B1-16-BR018

B1-16-BR020

B2-16-BR020 B2-16-BR032

Core

R0605

R0623

R0629

R0630

R0631

R0632

R0633

B3-16-FR006

B1-16-FR006 does not apply to DCMWC.

B3-16-BR018

DCMWC

R0606

R0607

B1-16-FR007

B1-16-BR008

DFEC

R0606

R0607

B2-16-FR007

B2-16-BR008

DEEOIC

R0603

B1-16-FR008

Core

R0606 R0608

R0616

R0617

R0637

R0638

R0644

B2-16-BR012 B1-16-BR021

B1-16-BR028

B3-16-BR035

Core

R0616

R0617

R0637

R0638

R0644

B3-16-BR021

B3-16-BR028

B3-16-BR035

DCMWC

R0618

R0619

R0618

R0619

B3-16-BR014

Core

R0610

R0614

R0625

R0643

B1-16-BR019

B2-16-BR019

Core

DCMWC

R0610

R0629

R0642

R0610

R0629

R0642

R0641

R0645

R0646

B1-16-FR017

R0641

R0645

R0646

B3-16-FR017

B1-16-FR017 does not apply to DCMWC.

R0615

R0626

B1-16-BR031

B3-16-BR031

Core

R0620

R0624

B1-16-FR019

B2-16-BR025

B3-16-BR025

Core

B3-16-BR034

DCMWC

4.2 Business Rules

· General Medical/Surgical

· Physical Therapy

· Travel and Transportation

· Durable Medical Equipment

· Contract nurse

· General Medical/Surgical form can be used for Ambulatory Surgical Centers and Home Health Services. Pharmacy request with NDC number can also come in this template.

· Physical Therapy form is limited for physical and occupational therapy or related services.

· Travel and Transportation is used for both mileage and transportation request.

· Durable Medical Equipment is used for any rental or purchase of medical equipment request.

· Contract nurse authorization request forms used for level 2 and 3 authorizations. The level 3 form contains additional information for the CE approving request’s signature.

DFEC

· General Medical/Surgical

· Physical Therapy

· Durable Medical Equipment

· Transplant

· Home Health

· General Medical/Surgical form can be used for Ambulatory Surgical Centers and Home Health Services. Pharmacy request with NDC number can also come in this template.

· Physical Therapy form is limited for physical and occupational therapy or related services.

· Durable Medical Equipment is used for any rental or purchase of medical equipment request.

· Transplant is used for transplant-related services

· Home Health is used for all RN/LPN, Hospice, and Home Health-related services.

DEEOIC

· The DFEC Program will edit on 2 diagnosis submitted on the Authorization Form. The submitted diagnoses will be compared concurrently with the accepted conditions on the claimant’s eligibility screen for processing consideration.

· Data from the scanned images/web portal will automatically be read and the request routed to the Contractor or DOL based on Authorization level.

· A combination of the CBP Portal and CBP Workflow must be used to provide an automated means for entering authorization requests, routing to the appropriate user (whether it’s the Contractor or District Office staff), and tracking each request through completion.

· Authorization decisions forwarded to the DOL claims examiners will contain a link to the authorization images including the authorization request and any supporting documentation and attachments.

· Based on the level, the workflow will route the request to either the Contractor or DOL as follows:

· Level 1: No Authorization required. Message will be communicated to the requester.

· Level 2: Routed to the Contractor Authorization unit for resolution. If the Contractor approves the request, the status will be updated in the system. If not, the undecided request will be escalated to L-3 and route to Claims Examiner (CE).

· Level 3: Routed to the appropriate District Office for resolution. Basically, the request will be in the CE inbox to work on. If CE decides the status is Approved/Under Review, the authorization letter goes out in 1 Business day. If denied, the CE will advise the Contractor through workflow tool.

DFEC

· For the DEEOIC program, the CBP should validate all diagnosis codes submitted on the authorization form. DEEOIC has revised the authorization request forms to limit the diagnosis dependant on the request to a max of 5 diagnoses.

· Data from the scanned images/web portal will automatically be read and the request routed to the Contractor or DOL based on Authorization level.

· A combination of the CBP Portal and CBP Workflow tool must be used to provide an automated means for entering authorization requests, routing to the appropriate user (whether it’s the Contractor or District Office staff), and tracking each request through completion.

· Authorization decisions forwarded to the DOL claims examiners will contain a link to the authorization images including the authorization request and any supporting documentation and attachments.

· Based on the level, the workflow will route the request to either the Contractor or DOL as follows:

· Level 1: No Authorization required. Message will be communicated to the requester.

· Level 2: Routed to the Contractor Authorization unit for resolution. If the Contractor approves the request, the status will be updated in to the system. If not, the undecided request will be escalated to L-3 and route to Claims Examiner (CE).

· Level 3: Routed to the appropriate District Office for resolution. Basically, the request will be in the CE inbox to work on. If CE decides the status is Approved/Under Review, the authorization letter goes out in 1 Business day. If denied, the CE will advise the Contractor through workflow.

DEEOIC

· Indexed images of faxed authorizations must be transmitted to iFECS as part of the DFEC imaging data file transmission.

· Authorizations submitted via fax should be evaluated for minimum required data, and sent back via fax if incomplete.

· Authorizations received via fax on an incorrect form should be returned as RTP via fax indicating an incorrect form was used, together with a full set of DOL approved blank authorization forms. The request should come in the correct and appropriate forms based on provider type.

Core

· Appropriate District Office staff should be given access to the CBP Portal and workflow tool to initiate Authorizations.

· CBP Portal should only allow enrolled, active providers to login and submit Authorization requests.

Core

Exception:

The following instances are NOT considered urgent, even if the request meets the criteria stated above.

· Cases in denied (C3) status

· Cases in closed status when the dates of service fall outside of the eligibility range

· Services that are level ones

· DME requests unless those directly related to surgery

· Any physical or occupational therapy

· A dedicated fax line for Contract Nurse Authorizations, as well as a dedicated IVR option for Contract Nurses to facilitate Urgent Authorization requests, must be established.

DFEC

· Inpatient admission, hospital transfers, or discharge from a facility, occurring within 3 business days

Or

· Open wound drainage including home nursing services, IV antibiotics and therapy, and/or dressing changes/supplies.

· Authorization requests received via the Triage Nurse as emergency authorization cannot be granted for Dates of Service already in the past/retroactive at the time of request.

· A dedicated fax line for Contract Nurse Authorizations, as well as a dedicated IVR option for Contract Nurses to facilitate Emergency Authorization requests, must be established.

DFEC

Terminal or discharge status ‘Home Health’ (HH)

· Authorization requests received via the Triage Nurse as emergency authorization cannot be granted for Dates of Service already in the past/retroactive at the time of request.

DEEOIC

B1-16-BR009